Artificial Tanning and Skin Cancer by pptfiles

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                  Artificial Tanning by Suburban Teenagers:
A Survey on the Prevalence of and Motivations for Indoor Tanning in the Midwest




                                  Robert Levine
                                 (847)/940-1872
                              levineboys@aol.com
                        Adlai E. Stevenson High School
                                 Lincolnshire, IL
                                                                Artificial Tanning   1


                                          Abstract

       Exposure to ultraviolet radiation (UVR), especially from artificial sources, has

been shown to increase the risk for skin cancers. Although the incidence of skin cancers

continues to climb in the United States, so too does the popularity of indoor tanning. A

stratified random sample of students from a large, Midwestern high school, known for its

academic excellence, was surveyed to quantify indoor tanning behaviors and sunscreen

use. Attitudes toward tanning and the knowledge of the health risk associated with it

were also examined.

       The percentage of respondents who tan indoors was 24%, increasing

significantly with age. More girls (37%) tanned than boys (8%), and teenagers began to

tan at a younger age. Most tanners (89%) indicated that they did so for appearance

related reasons. Tanners were more likely to have a family member who tanned than

non-tanners, and 11% of respondents reported having a parent who tanned. Although

only 37% of respondents reported seeing an advertisement that expressed the dangers

of tanning, a majority of students (92%) believed that indoor tanning was unhealthy.

Finally, half of respondents reported using sunscreen regularly, with girls doing so more

than boys.

       More teenagers than ever before are tanning indoors, disregarding substantial

evidence that links this behavior to skin cancer. The results of this study detail this

problematic trend and suggest a manner in which an educational campaign with

committed resources can produce effective intervention.
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                                        Introduction

       The prevalence of skin cancer in our society demands an understanding of its

causes if we are to control its proliferation. Over 1 million cases of nonmelanoma skin

cancer are diagnosed yearly, and it is estimated that 55,100 new cases of melanoma

will be diagnosed in 2004 alone (“Skin Cancer”, 2003, ¶ 1). Research has repeatedly

shown that increased exposure to ultraviolet radiation (UVR), especially from artificial

sources, can increase the risk for skin cancers. In the United States, the Skin Cancer

Foundation (SCF) estimates that 28 million people tan indoors annually (“Case Against”,

2003, ¶ 1). Prompting this research is the alarming rise in the popularity of artificial

tanning, a trend likened by some to cigarettes, with consequences of unforeseen

magnitude in the teenage population (Gutfeld & Sangiorgio, 1993, ¶ 1).

       The high proportion of teenagers who tan indoors suggests that today’s youth are

exposing themselves to increased levels of UVR (Geller et al., 2002). The short-term

effect, having tanned skin, is mainly aesthetic. The problem is that serious long-term

ramifications are often overlooked. The most common effects of exposure to UVR are

premature skin aging, wrinkles, loss of skin elasticity, the development of dark patches

(i.e. age spots or liver spots) and actinic keratoses, which are small rough or scaly spots

generally considered to be precursors to cancer (“Actinic Keratosis”, 2003; “Sunlight

and Ultraviolet Exposure”, 2003).

       These complications are minor compared to the heightened risk for developing

skin cancers, namely basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and

melanoma. Recent studies provide evidence for the connection between artificial

tanning and skin cancers. Karagas et al. (2002) found that compared to non-tanners,
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the use of tanning devices increased the likelihood of developing BCC by 1.5 times and

SCC by 2.5 times. It further concluded that for every ten years earlier that a subject

began use of a tanning device, the odds for BCC and SCC increased an additional 10%

and 20%, respectively (Karagas et al.).

       A recent study by Veierød et al. (2003) tracked rates of melanoma for an eight

year period in 106,379 women and found that a significantly increased risk of

contracting melanoma was associated with indoor tanning use. Another study found

similar results and noted that individuals who began artificial tanning before the age of

36 had 8.1 times greater risk for developing melanoma when compared to non-users

(Westerdahl, Ingvar, Måsbäck, Jonsson, & Olsson, 2000).

       Although evidence clearly links artificial tanning to an increased risk of skin

cancer, the majority of tanners seem willing to overlook it. A study of undergraduate

students at a large Midwestern university found that 47% of surveyed students had

used a tanning facility in the last year, while more than 90% of these students were

aware of possible complications (Knight, Kirincich, Farmer, & Hood, 2002). If today’s

youth realize that indoor tanning is dangerous, yet continue to patronize such facilities, it

is vital that we come to understand why.

       To that end, this research seeks to quantify indoor tanning behaviors and

pinpoint a student’s motivation for tanning indoors. Population data regarding sunscreen

and tanning bed use was collected at a large, suburban high school by surveying a

stratified random sample of students. In addition, the survey sought to determine

whether students understand the inherent dangers of tanning indoors and the extent to

which students have seen educational material about tanning. The student body of
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4,362 was selected to be surveyed because indoor tanning appears widespread, and

there is no known local campaign to educate students about its risks. This project can

corroborate other population-based studies, as well as provide the groundwork for

follow-up studies that can assess the effectiveness of implemented educational

interventions or track skin cancer rates.

                                            Methods

Participants

       The student body of a large, suburban high school was selected as the

population to be surveyed. This Midwestern high school has maintained a high degree

of academic excellence, having received the United States Department of Education

"Excellence in Education" Blue Ribbon award in 1987, 1991, 1998, and 2002 (“2002-

2003 Profile”, 2003). According to the Washington Post’s Jay Mathews, this high school

ranks 69th in the top public high schools in America (2003, table). The school is 84.2%

White, 0.9% Black, 2.9% Hispanic, 12.0% Asian or Pacific Islander, and 0.1% Native

American. (Illinois School Report Card, 2003, table “Students”). Please refer to Table 1

for further description of the student population.

Design and Procedure

       The student body was stratified by class, and a simple random sample was taken

from each grade level. This stratification was devised to better examine the

hypothesized increase in tanning rates among older adolescents. The sampling

procedure was designed to attain 100 responses from each grade in order to yield

statistically salient results while still maintaining a manageable number of participants.

Originally, 130 subjects were randomly selected in each grade, although an
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unexpectedly high non-response bias was apparent shortly after the survey began.

Subjects were randomly added one-by-one to each grade until 100 responses were

attained. As evident in Table 1, this procedure explains why each grade has a different

number of randomly selected students. Using the school’s published directory, in which

a large percentage of students are listed, each student received a number within their

class. A random number generator on the TI-89 was then used to select random

numbers from each class.

          Each subject was telephoned between January 1st, 2004, and February 1st, 2004.

Every willing subject responded to a survey, and responses were appropriately

recorded. In an effort to minimize response bias, the telephone survey was scripted so

that each subject heard the exact same instructions. The entire respondent survey can

be found in Appendix A.

Table 1. Class Size and Sampling Design
                                                         Number         Non-
                                        Sampling        Randomly     response     Number of
      Stratum        Enrollmenta         Spaceb         Selected      bias (%)    Responses

Freshmen                 1,143            1,071             150         33            100

Sophomore                1,158            1,110             174         43            100


Junior                   1,040             999              142         30            100


Senior                   1,021             972              163         39            100


Total                    4,362            4,152             629         36            400

a
    Enrollment as of January 5, 2004.
b
    Determined by the number of directory listings for that class.
                                                                     Artificial Tanning       5




Variables

       Demographics and skin color.

       Each respondent’s gender, age, and grade level was determined. Each was

asked to classify his or her skin color on the following scale: very fair, fair or average,

olive, or dark. This assessment was used to determine the approximate extent to which

their skin would burn with exposure to UVR. In general, when exposed to UVR, very fair

skin will burn and rarely tan; fair or average skin will tend to burn easily and tan

minimally; an olive complexion rarely will burn and tans well; and dark skin color will

almost never burn and will remain dark (“Darker Side”, 1996).

       Indoor tanning facility use.

       Each respondent was asked if he or she had ever been to a tanning salon. If the

respondent answered yes, he or she was asked more detailed questions about their

tanning behavior. The age when the respondent first tanned indoors was determined, as

was the number of times he or she tanned in the last year on a scale of 1 to 5, 6 to 10,

or greater than 10 times. Respondents were asked if they ever tanned for a school

dance, how often they usually visited the tanning salon, and how long they tanned at

each session. Finally, respondents answered true/false to descriptors that sought to

identify their motivations for tanning: aesthetic appearance, cost, peer pressure, or in

preparation for vacation. If the respondent had never been to a tanning salon, he or she

responded to a series of true/false descriptors that sought to identify the reason: no

desire, knowledge of the dangers, limited time, or cost.
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      Understanding the danger.

      To assess whether students understand the danger of indoor tanning, two

questions were asked. Towards the beginning of the survey, students were asked: “Do

you think artificial tanning is healthy?” Towards the end of the survey, students were

asked: “Do you think artificial tanning is safe?” The subtle difference was intended to

determine whether students truly understood the question, as well as assess the

number of students who wavered on the question or changed their answer.

      Sunscreen use.

      Each respondent was asked whether he or she regularly used sunscreen. This

quantified a major risk factor in the development of skin cancer.

      Familial tanning.

      Each respondent was asked whether anyone in their immediate family tanned

indoors. This variable was included because previous studies have shown there may

be a link between teenage tanning and parental tanning (Cokkinides, Weinstock,

O'Connell, & Thun, 2002).

      Advertisements.

      Each respondent was asked whether he or she had ever seen advertisements for

tanning salons. This was followed by a question that asked if students had ever seen

educational signs or advertisements expressing the dangers of tanning. This variable,

along with the student’s understanding of the dangers of tanning, helped quantify the

effectiveness of educational campaigns.
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       Mobility.

       Each respondent was asked if he or she had a driver’s license and access to a

car. It is hypothesized that students who want to patronize tanning salons will be more

inclined to go if they are not dependent on their parents or older siblings to drive them.

       Risky behaviors.

       Each respondent was asked if he or she smoked cigarettes, a behavior that has

been linked in a previous study to higher tanning rates (Welchsler, Rigotti, Gledhill-Hoyt,

& Lee, 1998).


Statistical Analysis.

       Data from each grade was compiled in a spreadsheet and then transferred to a

statistical analysis program, Fathom Dynamics Statistics Software™. For each variable,

the percentage of the sample population that responded in a particular way was

determined, along with the 95% confidence interval (CI) that estimated the percentage

of the entire population that exhibited that characteristic. The effects of different

variables were considered by multivariate data analysis and significance was

determined by two-proportion Z-tests with an alpha level of .05.
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                                         Results

       The survey included a total of 400 students, with 182 male and 218 female

respondents. A frequency distribution of the population surveyed can be found in Table

2. Overall, 24% (95% CI = 0.20 to 0.28) of all respondents tanned indoors. As

respondent age increased, so too did the percentage that tanned indoors. Table 3

shows this significant trend, along with the observation that girls tanned more than boys.

Skin color apparently did not affect indoor tanning habits of respondents. Over half of all

tanners (57%, [95% CI= 0.47 to 0.67]) reported that they tanned indoors 1-5 times in the

last year, although 70% (95% CI= 0.58 to 0.83) of these tanners indicated no regular

schedule for this activity. When students tanned indoors, the majority of these sessions

lasted 15 minutes (34%, [95% CI= 0.24 to 0.43]) or 20 minutes (39%, [95% CI=0.29 to

0.49]), with no significant differences between grades. Surveyed tanners indicated they

began tanning at a mean age of 14.72 years (95% CI= 14.46 to 14.97). The mean age

at which freshmen respondents began tanning (13.33 years, [95% CI= 12.65 to 14.02])

was significantly lower than that of juniors (14.93 years, [95% CI= 14.51 to 15.36]) and

seniors (15.38 years, [95% CI= 14.94 to 15.81]).

       When respondents were questioned about why they tanned indoors, most

tanners (89%, [95% CI= 0.83 to 0.93]) indicated that they did so because they liked the

way it made them look. Table 4 shows that significantly more Freshmen and Junior

tanners specified that they also went tanning to achieve a base layer prior to vacation.

Tanning prior to a school dance was measured and 66% (95% CI= 0.57 to 0.76) of all

tanners reported such behavior. Interestingly enough, however, 81% (95% CI= 0.73 to
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0.89) of tanners reported that having friends who tanned was not a motivation for

tanning. Likewise, the cost of tanning did not appear to be relevant.

       When non-tanners were questioned about their reasons for not tanning, 91%

(95% CI= 0.87 to 0.94) cited no desire to tan indoors. As Table 5 indicates, the majority

(73%, [95% CI=0.68 to 0.78]) indicated that they refrained from tanning because they

knew it was dangerous. Limited time and lack of money were not relevant factors.

       The impact of having a family member who tans was studied. The survey found

that 25% (95% CI= 0.21 to 0.29) of all respondents had one or more family members

who tanned indoors. Of the tanners, 47% (95% CI= 0.37 to 0.57) reported having a

family member who tanned, while only 18% (95% CI= 0.14 to 0.22) of respondents who

didn’t tan reported such. Furthermore, 11% (95% CI= 0.08 to 0.14) of respondents

reported that a parent tanned indoors.

       A large majority of all surveyed students (92%, [95% CI= 0.89 to 0.95])

expressed the belief that artificial tanning is unhealthy. As Table 6 shows, no significant

variation was seen between tanners versus non-tanners, though girls were more likely

to think tanning was unhealthy (z=2.75, p<.006). Of interest, a variation on this question

showed that 13% (95% CI= 0.10 to 0.17) of respondents believed indoor tanning to be

safe, a significantly higher proportion than thought it to be healthy (8.0%, [95% CI=0.05

to 0.11], z=2.41, p<0.016). Furthermore, exposure to educational advertisements about

the dangers of tanning had no effect on a student’s opinion on this matter. While 37%

(95% CI=0.33 to 0.42) of all respondents indicated they had seen advertisements

expressing the dangers of tanning, more than twice that amount, 81% (95% CI=0.77 to

0.84), reported having seen advertisements for tanning salons.
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         Half of all students surveyed (95% CI = 0.45 to 0.55) indicated that they regularly

used sunscreen. These results are shown in Table 7. Overall, more girls reported

regular sunscreen use than boys (z=2.50, p<.012). Respondents with very fair or

average skin color used sunscreen more often than respondents with olive or dark skin.

         While most everyone of driving age indicated they had a license and access to a

car, this variable proved to have little effect on tanning behaviors. Finally, the number of

respondents who reported that they smoked was so small that it was deemed unusable

and not considered as a factor in tanning behavior.


Table 2. Sample Frequency Distribution
                    Gender        Age                          Skin Type
     Grade                                       Very    Fair or
                   M      F      Mean            Fair   Average      Olive       Dark
Freshmen              45       55      14.32       9      74          15           2

Sophomore             52       48      15.36       6      71          19           4

Junior                39       61      16.31       9      70          15           6

Senior                46       54      17.36      11      72          14           3

All Respondents       182     218      15.84      35      287         63          15
Note. Each grade has n=100. All Respondents is N=400.
                                                                            Artificial Tanning   11


Table 3. Prevalence of Indoor Tanning Salon Use
        Grade            Proportion who Tan    P-values

  Freshmen
      Total (n=100)          0.12 (0.06 to 0.18)
      Male (n=45)            0.02 (0.00 to 0.12)
      Female (n=55)
                                                       ] .0065
                             0.20 (0.09 to 0.31)

  Sophomore
      Total (n=100)          0.21 (0.13 to 0.29)
      Male (n=52)            0.04 (0.00 to 0.13)
                                                       ] .0000
      Female (n=48)          0.40 (0.26 to 0.53)

  Junior
      Total (n=100)          0.30 (0.21 to 0.39)
      Male (n=39)            0.10 (0.03 to 0.24)
                                                       ] .0005
      Female (n=61)          0.43 (0.30 to 0.55)

  Senior
      Total (n=100)          0.32 (0.23 to 0.41)
      Male (n=46)            0.17 (0.08 to 0.31)
      Female (n=54)
                                                       ] .0039
                             0.44 (0.31 to 0.58)

  All Respondents
      Total (N=400)          0.24 (0.20 to 0.28)
      Male (n=182)           0.08 (0.04 to 0.12)
                                                       ] .0000
      Female (n=218)         0.37 (0.30 to 0.43)
Note. Sample proportions are given as the decimal followed by the 95% CI.
To test the Ho (proportion “male” and proportion “female” are equal) a
two-proportion Z-test was used. All P-values are two-sided.
                                                                             Artificial Tanning       12


Table 4. Motivational Analysis of Indoor Tanners
  Descriptor          Grade         Responded True               Responded False          P-values

                     Freshmena           0.92 (0.62 to 1.00)     0.08 (0.00 to 0.38)      .0000
I went tanning                       b
                     Sophomore           0.86 (0.64 to 0.97)     0.14 (0.03 to 0.36)      .0000
because I like                   c
                     Junior              0.87 (0.69 to 0.96)     0.13 (0.04 to 0.31)      .0000
how it makes
me look.             Seniord             0.94 (0.79 to 0.99)     0.06 (0.01 to 0.21)      .0000
                     Totale              0.89 (0.83 to 0.93)     0.11 (0.04 to 0.17)      .0000

I went tanning       Freshmena           0.25 (0.05 to 0.57)     0.75 (0.43 to 0.95)      .0143
because I got                        b
                     Sophomore           0.29 (0.11 to 0.52)     0.71 (0.48 to 0.89)      .0050
coupons or it                    c
                     Junior              0.27 (0.12 to 0.46)     0.73 (0.54 to 0.88)      .0003
was                              d
inexpensive.         Senior              0.22 (0.09 to 0.40)     0.78 (0.60 to 0.91)      .0000
                             e
                     Total               0.25 (0.17 to 0.34)     0.75 (0.66 to 0.83)      .0000

                     Freshmena           0.25 (0.05 to 0.57)     0.75 (0.43 to 0.95)      .0143
I went tanning                       b
                     Sophomore           0.29 (0.11 to 0.52)     0.71 (0.48 to 0.89)      .0050
because many                     c
                     Junior              0.13 (0.04 to 0.30)     0.87 (0.70 to 0.96)      .0000
of my friends                    d
do it.               Senior              0.16 (0.05 to 0.33)     0.84 (0.67 to 0.95)      .0000
                             e
                     Total               0.19 (0.11 to 0.27)     0.81 (0.73 to 0.89)      .0000

                     Freshmena           0.83 (0.52 to 0.98)     0.17 (0.02 to 0.48)      .0011
I went tanning                       b
to get a base        Sophomore           0.62 (0.38 to 0.82)     0.38 (0.18 to 0.62)      .6190
                                 c
layer before         Junior              0.67 (0.50 to 0.84)     0.33 (0.17 to 0.50)      .0098
going on             Senior      d
                                         0.59 (0.42 to 0.76)     0.41 (0.24 to 0.58)      .1336
vacation.
                     Totale              0.65 (0.56 to 0.75)     0.35 (0.25 to 0.44)      .0000

                     Freshmena           0.42 (0.15 to 0.72)     0.58 (0.28 to 0.85)      .4142
                                     b
I went tanning       Sophomore           0.67 (0.43 to 0.85)     0.33 (0.15 to 0.57)      .0308
                                 c
for a school         Junior              0.77 (0.58 to 0.90)     0.23 (0.10 to 0.42)      .0000
dance.               Senior      d
                                         0.66 (0.49 to 0.82)     0.34 (0.18 to 0.51)      .0124
                             e
                     Total               0.66 (0.57 to 0.76)     0.34 (0.24 to 0.43)      .0000
Note. Sample proportions are given as the decimal followed by the 95% CI. These are based on the total
for each stratum and may not total to 1 due to rounding. To test the Ho (proportion “responded true” and
proportion “responded false” are equal) a two-proportion Z-test was used. All P-values are two-sided.
a       b       c      d        e
  n=12; n=21; n=30; n=32 ; n=95
                                                                            Artificial Tanning   13


Table 5. Motivational Analysis of Non-Tanners
  Descriptor          Grade        Responded True                Responded False

                     Freshmena         0.86 (0.79 to 0.94)      0.14 (0.06 to 0.21)

I have no            Sophomoreb        0.95 (0.88 to 0.99)      0.05 (0.01 to 0.13)
desire to go
                     Juniorc           0.90 (0.81 to 0.96)      0.10 (0.04 to 0.20)
artificial
tanning.             Seniord           0.91 (0.82 to 0.97)      0.09 (0.03 to 0.18)
                     Totale            0.90 (0.87 to 0.94)      0.10 (0.06 to 0.13)

                     Freshmena         0.69 (0.60 to 0.79)      0.31 (0.21 to 0.40)

I don’t go       Sophomoreb            0.72 (0.62 to 0.82)      0.28 (0.18 to 0.38)
tanning
                 Juniorc               0.81 (0.72 to 0.91)      0.19 (0.09 to 0.28)
because I know
it is dangerous. Seniord               0.69 (0.58 to 0.80)      0.31 (0.20 to 0.42)
                     Totale            0.73 (0.68 to 0.78)      0.27 (0.22 to 0.32)

                     Freshmena         0.33 (0.23 to 0.43)      0.67 (0.57 to 0.77)
I don’t go           Sophomoreb        0.33 (0.23 to 0.43)      0.67 (0.57 to 0.78)
tanning
because I don’t      Juniorc           0.34 (0.23 to 0.45)      0.66 (0.55 to 0.77)
have enough
time.                Seniord           0.19 (0.01 to 0.28)      0.81 (0.72 to 0.90)
                     Totale            0.30 (0.25 to 0.35)      0.70 (0.65 to 0.75)

                     Freshmena         0.13 (0.06 to 0.19)      0.88 (0.81 to 0.94)
I don’t go           Sophomoreb        0.13 (0.05 to 0.20)      0.87 (0.80 to 0.95)
tanning
because I don’t      Juniorc           0.20 (0.11 to 0.29)      0.80 (0.71 to 0.89)
have the
money.               Seniord           0.12 (0.05 to 0.22)      0.88 (0.78 to 0.95)
                     Totale            0.14 (0.10 to 0.18)      0.86 (0.82 to 0.90)
Note. Sample proportions are given as the decimal followed by the 95% CI. These are based
on the total for each stratum and may not total to 1 due to rounding. Two-proportion Z-tests
showed that all tests of Ho (proportion “responded true” and proportion “responded false”
are equal) demonstrated significance at the .01 level. All P-values were two-sided.
a       b        c       d      e
  n=88; n=79; n=70; n=68 ; n=305
                                                                           Artificial Tanning   14


Table 6. Exposure to Advertisements and Attitudes Towards Indoor Tanning
  Descriptor          Grade         Sample Proportion       P-values

                     All Respondentsa       0.08 (0.05 to 0.11)
Respondents        Tannersb                 0.09 (0.04 to 0.17)
who think                                                            ].5443
                   Non-tannersc             0.08 (0.05 to 0.11)
artificial tanning
is healthy.        Maled                    0.12 (0.07 to 0.17)
                              e                                      ].0059
                     Female                 0.05 (0.02 to 0.07)

                     All Respondentsa 0.13 (0.10 to 0.17)
Respondents          Tannersb              0.21 (0.13 to 0.29)
who think                                                            ].0102
                     Non-tannersc          0.11 (0.07 to 0.14)
artificial tanning
is safe.             Maled                 0.16 (0.11 to 0.21)
                                                                     ].1480
                     Femalee               0.11 (0.07 to 0.15)

                     All Respondentsa 0.81 (0.77 to 0.84)
Respondents
                     Tannersb              0.77 (0.68 to 0.85)
who have seen                                                        ].3028
advertisements       Non-tannersc          0.82 (0.77 to 0.86)
for tanning          Maled                 0.80 (0.74 to 0.86)
salons.                                                              ].7020
                     Femalee               0.81 (0.76 to 0.86)

Respondents          All Respondentsa 0.37 (0.33 to 0.42)
who have seen        Tannersb              0.60 (0.50 to 0.70)
advertisements                     c                                 ].0000
                     Non-tanners           0.30 (0.25 to 0.35)
expressing the
dangers of           Maled                 0.23 (0.17 to 0.29)
tanning.                      e                                      ].0000
                     Female                0.49 (0.42 to 0.56)
Note. Sample proportions are given as the decimal followed by the 95% CI. Two-proportion
Z-tests were used to determine significance. All P-values are two-sided.
a        b      c         d        e
  N=400; n=95; n=305; n=182 ; n=218
                                                                           Artificial Tanning      15


Table 7: The Prevalence of Regular Sunscreen Use
           Grade              Proportion who Use Sunscreen                       P-values
  Freshmen
    Total (n=100)                           0.64 (0.55 to 0.73)
     Male (n=45)                            0.49 (0.34 to 0.63)
     Female (n=55)                          0.76 (0.65 to 0.88)
                                                                            ] .0044
     Very Fair or Fair (n=83)               0.69 (0.59 to 0.79)
     Olive or Dark (n=17)                   0.41 (0.18 to 0.67)
                                                                            ] .0314

  Sophomore
     Total (n=100)                          0.40 (0.30 to 0.50)
     Male (n=52)                            0.37 (0.24 to 0.50)
     Female (n=48)                          0.44 (0.30 to 0.58)
                                                                            ] .4621
     Very Fair or Fair (n=77)               0.45 (0.34 to 0.57)
     Olive or Dark (n=23)                   0.22 (0.07 to 0.44)
                                                                            ] .0416

  Junior
    Total (n=100)                           0.49 (0.39 to 0.59)
     Male (n=39)                            0.46 (0.31 to 0.62)
     Female (n=61)                          0.51 (0.38 to 0.63)
                                                                            ] .6489
     Very Fair or Fair (n=79)               0.56 (0.45 to 0.67)
     Olive or Dark (n=21)                   0.24 (0.08 to 0.47)
                                                                            ] .0094

  Senior
   Total (n=100)                            0.48 (0.38 to 0.58)
     Male (n=46)                            0.43 (0.29 to 0.58)
     Female (n=54)                          0.52 (0.39 to 0.65)
                                                                            ] .4035
     Very Fair or Fair (n=83)               0.51 (0.40 to 0.61)
     Olive or Dark (n=17)                   0.35 (0.14 to 0.62)
                                                                            ] .2497

  All Respondents
    Total (N=400)                           0.50 (0.45 to 0.55)
     Male (n=182)                           0.43 (0.36 to 0.51)
     Female (n=218)                         0.56 (0.49 to 0.63)
                                                                            ] .0124
     Very Fair or Fair (n=322)              0.55 (0.50 to 0.61)
     Olive or Dark (n=17)                   0.29 (0.19 to 0.40)
                                                                            ] .0000
Note. Sample proportions are given as the decimal followed by the 95% CI. Two-proportion Z-tests
were used to determine significance. All P-values are two-sided.
                                                                  Artificial Tanning      16


                                        Discussion

       This study quantified information about teenagers who tan indoors and sought a

thorough investigation of their motivations for such behavior. Its findings show that a

sizeable minority (24%) of students at a large suburban high school have patronized a

tanning salon in the last year. As Table 3 illustrates, gender and age were determining

factors in whether students tanned. As expected, significantly more girls tanned than

boys, attributed to the increasing social pressure to appear tan and the heightened

willingness of girls to invest in their appearances.

       While being considerable, the prevalence of indoor tanning observed is not

extraordinary when compared to the pool of national surveys that have documented

similar trends. A study conducted in 1999 by Geller et al. (2002) of 10,079 American

adolescents age 12 to 18, showed that 10% of respondents patronized an indoor

tanning salon in the previous year. Girls reported far greater tanning bed use (14%)

than boys (2.4%), and tanning bed use increased from 7% among girls age 14, to 16%

by age 15, and then doubled to 35% by age 17. Although the data collected show

almost twice the prevalence of indoor tanning than demonstrated in this study, the

overall trends in tanning salon use are similar.

       Similarly, a study of 6,903 non-Hispanic White adolescents in the United States

found that 36.8% of females and 11.2% of males have been indoor tanning at least

once, and 28.1% of females and 6.9% of males reported indoor tanning three or more

times (Demko, Borawski, Debanne, Cooper, & Stange, 2003). In addition, the Demko et

al. study showed that the percentage of female adolescents using artificial tanning 3 or

more times increased with age: only 11.2% of the 13 to 14 year-olds reported tanning 3
                                                                     Artificial Tanning     17


or more times, compared with 47.0% of the 18 to 19 year-olds. Furthermore, the study

highlighted an interesting geographical explanation as to why many Midwestern

teenagers tan indoors: “the risks of artificial tanning need increased emphasis among

adolescents, especially in the Midwest and South where extremes in the availability of

natural light appear to send intentional tanners indoors”(p. 854). This may explain why

more teenagers in the Midwest, like those surveyed, tan indoors than the numbers that

tan on a national level.

       Obviously, the popularity of indoor tanning is on the rise, and it is evident that

those who tan indoors are beginning to do so at a younger age. On average, freshmen

tanners began tanning at a significantly younger age than juniors or seniors, indicating

that this trend will only continue to become more serious with time. It is important to

note that local legislation in the area where this study was conducted currently bans

teenagers less than 14 years of age from tanning and requires parental consent for 14

to 17 year-olds. However, there is evidence to suggest poor compliance with this law,

as 18% (95% CI= 0.10 to 0.26) of tanners surveyed would have been unable to tan

indoors at their first visit if this legislation had been enforced. Other studies have

similarly documented poor compliance with state and federal regulations. One study of

50 tanning facilities in North Carolina found that 95% of patrons exceeded FDA

recommended exposure limits (Hornung, Magee, Lee, Hansen, & Hsieh, 2003).

Another study in San Diego found that 43% of tanning salons failed to comply with

parental consent regulations (Culley, et al., 2001). As a whole, the tanning industry has

effectively fought attempts by various organizations to bring national legislation
                                                                   Artificial Tanning      18


regulating indoor tanning, although it seems apparent that such legislation, if enforced,

would help safeguard today’s youth from the harmful effects of UVR.

       Further analysis of the data collected for this study revealed that most tanners

(57%) lacked a schedule for tanning and reported having only tanned between one to

five times in the last year. Yet, 19% (95% CI= 0.11 to 0.29) of respondents who tanned

specified that they did so more than 10 times in the last year. Sessions typically lasted

15 or 20 minutes, with no variation between the grade levels. The somewhat sporadic

nature of tanning behavior may indicate that students tan indoors for specific events,

rather than having an established regimen.

       An important goal of this research was to collect data on why students tanned

indoors. As Table 4 demonstrates, the results of a multivariate analysis showed that the

desire for a tanned appearance was the most prevalent incentive. Tanning for a school

dance was also an important factor, giving credence to the idea that girls feel obligated

to tan for social reasons. Unexpectedly, peer pressure did not play as large a role in a

student’s decision to tan. This may be attributed to the individual nature of going to a

tanning salon, along with the desire for teenagers to appear independent.

       Significant numbers of freshmen and juniors also went tanning prior to vacation,

under the pretext of achieving a base layer. This concept is touted by the tanning

industry, as evident in literature produced by the International Smart Tan Network

(2002): “Every year, millions of indoor tanners successfully develop "base tans" before

embarking on sunny vacations - tans that, combined with the proper use of sunscreen

outdoors, help them prevent sunburn.” Although this statement may not be false,
                                                                   Artificial Tanning    19


achieving a “base tan” results in more UVR exposure than a person would ordinarily

receive, possibly increasing the likelihood of developing skin cancers.

       The link between increased UVR exposure and skin cancer has been the subject

of recent studies. Veierød, et al (2003) concluded that the use of an indoor tanning

salon at any age increased the risk of developing melanoma by 55%. Furthermore,

they noted that “adolescence and early adulthood appear to be among the most

sensitive age periods for the effects of sunburn and solarium use on melanoma risk”

(p.1530). Similarly, increased UVR exposure has been associated with increased risks

for BCC and SCC, as found by Karagas et al. in 2002.

       These studies, while implicating UVR in the development of skin cancers, relied

on older subjects (ages 25–74 in Karagas et al; and ages 30-50 years in Veierød, et al)

to remember details about their past tanning salon practices. Although any survey is

limited by the honesty of respondents and their ability to recall specifics from years ago,

a strength of this study is the age group that was surveyed. Young respondents could

provide reliable information about their recent tanning history. By documenting the

extent to which teenagers use indoor tanning salons, rates of skin cancer can be

tracked in the future to examine if the incidence of skin cancer can be attributed to

increased UVR exposure by artificial tanning. A follow-up study of this nature would be

of great value in providing evidence for this potential association.

       When analyzing how much UVR exposure a teenager receives, regular use of

sunscreen is an important indicator. Half of all surveyed students indicated that they

regularly used sunscreen, with freshmen having the highest proportion (64%) and

sophomores having the lowest (40%). As Table 7 demonstrates, significantly more
                                                                  Artificial Tanning       20


females reported regular sunscreen use than males, supporting previous studies that

have shown similar findings (Geller et al., 2002). It was expected that skin color would

affect sunscreen use, and it was observed that those with very fair or average skin used

sunscreen regularly more so than those with olive or dark skin. The most surprising

finding here is that more students do not use sunscreen on a regular basis, even after

extensive efforts to educate students about its importance.

      A similar discrepancy occurs with regard to education about artificial tanning.

Table 6 details the exposure surveyed students had to various advertising, as well as

their beliefs regarding the dangers of tanning. Although the vast majority of students

(92%) thought artificial tanning was unhealthy, having seen educational material made

no difference in their beliefs. However, tanners were more likely to have seen

educational material than non-tanners. Interestingly, whether or not a respondent had

gone tanning did not affect whether they had seen advertisements for tanning salons.

This suggests that the tanning industry has effectively marketed their services to

teenagers and that teenagers are learning about the dangers of tanning more from

tanning salons then from any other source.

      This poses a significant problem that signals the limited nature of national

campaigns to educate the public about the dangers of tanning. Currently, The Centers

for Disease Control and Prevention (CDC) hosts the “National Melanoma/Skin Cancer

Detection and Prevention Month” each May and publishes “Guidelines for School

Programs to Prevent Skin Cancer.” Other organizations, such as the American Cancer

Society and the American Academy of Dermatology have accessible web pages and

produce pamphlets. Yet each of these organizations, while attempting outreach, would
                                                                   Artificial Tanning    21


benefit from improvement with their efforts. In the communities where this survey was

conducted, no educational material about skin cancer or artificial tanning could be found

in any schools. There is evidently a lack of educational resources committed to this

problem.

       With national attention focused on epidemics such as AIDS and SARS and

issues such as teen pregnancies and drug abuse, one must question why the trend in

artificial tanning has been so overlooked. The most likely explanation is the concept of

immediacy. AIDS, SARS, teen pregnancies and drug abuse all have swift

consequences that activists can focus on, whereas indoor tanning provides immediate

fulfillment but has delayed ramifications. Although there is a fear that today’s teenagers

will be tomorrow’s cancer patients, the tanning industry continues to grow with little

legislative restraint, threatening to engage more teenagers in the dangerous behavior of

indoor tanning. Although 73% (95% CI=0.68 to 0.78) of respondents who didn’t tan

indicated they refrained from tanning because they knew it was dangerous, the link

between education and action is lacking. A recent survey of Midwestern teens indicated

that most knew that excessive sun exposure was unhealthy, but that didn’t stop them

from burning (Robinson, Rademaker, Sylvester, Cook, 1997). This is the essential

problem faced by those who seek to curb this trend.

       It is necessary therefore to develop an educational campaign that is more than

just pamphlets and advertisements. School systems, where students are potentially

educable and the infrastructure exists to implement a well-designed campaign, must

take action. The school where this study was conducted holds different “Awareness

Weeks” on a frequent basis, each one educating students about a different subject. It is
                                                                     Artificial Tanning      22


surprising that there has never been a week highlighting the dangers of tanning, nor

even interest in such a campaign. In addition, each sophomore is required to take a

health class, but a unit about the dangers of artificial tanning is not in the curriculum.

Clearly, this school does not stand alone; there are similar institutions across the nation

that would benefit from such programs.

       Finally, it is the responsibility of parents and doctors to get involved as well. An

adult educational campaign might prove as useful as one directed at students,

considering that 11% (95% CI= 0.08 to 0.14) of respondents indicated that a parent in

the household went tanning. If parental consent is required until the age of 18, educated

parents could curtail their own use of tanning salons and stop their children from tanning

at a young age.

       Ultimately, the prevalence of tanning indoors may be the product of a society

focused on aesthetic appearances and one which is willing to overlook long-term

ramifications. With the knowledge of why students tan indoors, more effective

educational campaigns can be created to stem this trend. One of the strengths of this

study was the pointed questions it asked of both tanners and non-tanners alike.

Questions were designed to gather as much useful information as possible without

asking students to recall facts they probably could not, such as the exact number of

tanning salon visits in the last year, the type of UVR exposure they had, and the extent

to which they were naturally exposed the UVR. Furthermore, to my knowledge, this

study is the first which analyzes the motivations of students at a single high school,

providing data on class-specific factors that shed light on how tanning behaviors mirror

the school environment. Students surveyed are receiving one of the best educations in
                                                                   Artificial Tanning    23


the United States, yet this is not apparent in the widespread use of tanning salons.

Finally, by comparing this study to others performed in different geographic regions, the

extent to which location is a factor in tanning behavior can be determined.

        A limitation of this study was the homogeneity of the population surveyed. In

addition, some variables were deemed unusable due to the nature of responses. It is

likely that in a series of questions that were not highly invasive, students were surprised

to be asked whether or not they smoked. Anecdotal evidence would suggest that many

respondents hesitated to answer this question and then proceeded to answer “no.” The

variable was examined because previous research had linked artificial tanning to other

risky behaviors such as smoking (Welchsler, Rigotti, Gledhill-Hoyt, & Lee, 1998).

Finally, while non-response bias was not exceptionally high, little attempt was made to

analyze those who refused the survey.

        In the near future, a continuation of this study would begin by analyzing the

effects of more pervasive educational intervention. Respondents of this survey would be

contacted so that any change in their behavior or attitudes toward indoor tanning could

be measured. This research would provide feedback to the creators of the educational

campaign, allowing them to determine the most effective measures before attempting to

introduce the program at another school. In an effort to sway public opinion, a

nationwide, school-based initiative would likely be the most effective means of helping

students realize the dangers they expose themselves to by patronizing indoor tanning

facilities.
                                                                      Artificial Tanning   24


                                             References

American Academy of Dermatology. (1996). The darker side of tanning.

       Retrieved December 30, 2003, from http://www.aad.org/pamphlets/

       darker.html

Cokkinides, V. E., Weinstock, M. A., O'Connell, M. C., & Thun, M. J. (2002). Use

       of indoor tanning sunlamps by US youth, ages 11-18 years, and by their parent

       or guardian caregivers: prevalence and correlates [electronic version]. Pediatrics.

       Retrieved on January 15, 2004, from http://www.findarticles.com/cf_dls/

       m0950/6_109/87564111/print.jhtml

Culley, C. A., Mayer, J. A., Eckhardt, L., Busic, A. J., Eichenfield, L. F., Sallis, J.

       F., Quintana, P. J. E., & Woodruff, S. I. (2001). Compliance with federal and state

       legislation by indoor tanning facilities in San Diego [Abstract]. Journal of

       American Academy of Dermatology, 44, 53-60.

Demko, C. A., Borawski, B. A., Debanne, S. M., Cooper, K. D., & Stange, K. C.

       (2003). Use of indoor tanning facilities by white adolescents in the United States.

       Archives of Pediatric Adolescent Medicine, 157, 854-860.

Geller A. C., Colditz G., Oliveria S., Emmons K., Jorgensen C., Aweh, G. N., &

       Frazier A. L. (2002). Use of sunscreen, sunburning rates, and tanning bed use

       among more than 10 000 US children and adolescents. Pediatrics, 109, 1009-

       1014.

Gutfeld, G., & Sangiorgio, M. (1993, May). Fake and bake. Prevention, 45(5), 6.

       Retrieved December 29, 2003, from MAS Ultra - School Edition database.
                                                                   Artificial Tanning   25


Hornung, R. L., Magee, K. H., Lee, W. J., Hansen, L. A., & Hsieh, Y. (2003).

       Tanning facility use: Are we exceeding Food and Drug Administration limits?

       [Abstract]. Journal of American Academy of Dermatology, 49, 655-61.

The International Smart Tan Network. (2002). The fundamental truth about

       tanning. Retrieved December 29, 2003, from http://www.tanningtruth.com/

       page.php

Karagas, M. R., Stannard, V. A., Mott, L. A., Slattery, M. J., Spencer, S. K., &

       Weinstock, M. A. (2002). Use of tanning devices and risk of basal cell and

       squamous cell skin cancers [Electronic version]. Journal of the National Cancer

       Institute, 94, 224-226.

Knight, J. M., Kirincich, A. N., Farmer, E. R., & Hood, A. F. (2002). Awareness of

       the risks of tanning lamps does not influence behavior among college students.

       Archives of Dermatology, 138, 1311-1315.

Mathews, Jay. (2003). The most challenging American high schools. The

       Washington Post Company. Retrieved on January 1, 2004, from

       http://www.washingtonpost.com/wpsrv/education/shoulders/challenge/2003nation

       alindex.htm

Robinson, J. K., Rademaker, A. W., Sylvester, J. A., & Cook, B. (1997).

       Summer sun exposure: Knowledge, attitudes, and behaviors of Midwest

       adolescents. Preventive Medicine, 26(3), 364-372.

The Skin Cancer Foundation. (2003). Actinic keratosis: What you should know

       about this common precancer. Retrieved January 24, 2004, from

       http://www.skincancer.org/ak/index.php
                                                                   Artificial Tanning   26




The Skin Cancer Foundation. (2003). The case against indoor tanning.

       Retrieved December 29, 2003, from http://www.skincancer.org/

       artificial/index.php

The Skin Cancer Foundation. (2003). Skin cancer facts. Retrieved January 24,

       2004, from http://www.cancer.org/docroot/PED/content/ped_7_1_

       What_You_Need_To_Know_About_Skin_Cancer.asp?sitearea=PED

The Skin Cancer Foundation. (2003). Sunlight and ultraviolet exposure.

       Retrieved January 24, 2004, from http://www.cancer.org/docroot/PED/

       content/ped_7_1_What_You_Should_Know_About_Ultraviolet_Exposure.asp?sit

       earea=PED

2002-2003 Profile of: XXXX High School. (2003). Retrieved

       January 1, 2004, from http://www8.district125.k12.il.us/docs/profiles/

       profile0203.html

Veierød, M. B., Weiderpass, E., Thörn, M., Hansson J., Lund, E., Armstrong, B.,

       & Adami, A. (2003). A prospective study of pigmentation, sun exposure, and risk

       of cutaneous malignant melanoma in women. Journal of the National Cancer

       Institute, 95, 1530-1538.

Welchsler, H., Rigotti, N. A., Gledhill-Hoyt, J., & Lee, H. (1998). Increased levels

       of cigarette use among college students: a cause for national concern. Journal of

       the American Medical Association, 280, 1673-1678.
                                                                 Artificial Tanning   27




Westerdahl J., Ingvar C., Masback A., Jonsson N., & Olsson H. (2000). Risk of

      cutaneous malignant melanoma in relation to use of sunbeds: further evidence

      for UV-A carcinogenecity [Electronic version]. British Journal of Cancer, 82,

      1593-1599.

XXXX High School. (2003). Illinois School Report Card.
                                                                                          Artificial Tanning   28


                                                     Appendix A

                                          Respondent Survey 2004

Hello, my name is XXXX and I am a student at XXXXX High School. I am conducting a survey about the
effects of artificial tanning. Please, do you have a minute to answer a few questions? Thank you.

First, what is your gender?                   Male (1)                    Female (2)

How old are you?                  14          15       16        17       18       19
                           th                   th                 th                th
What grade are you in? 9 (1)                  10 (2)             11 (3)            12 (4)

What is the normal color of your skin when it is not tan on the following scale?
        very fair (1)   fair or average (2)       olive (3)         dark (4)

Do you regularly use sunscreen?                        Yes (1)            No (2)

Do you think artificial tanning is healthy?            Yes (1)            No (2)

Have you ever been to a tanning salon?                 Yes (1)            No (2)

(IF NO, SKIP THIS NEXT LINE OF QUESTIONING)
IF YES:
         At what age did you first visit a tanning salon?
               10 11 12 13 14 15 16 17 18                                 19

            How many times have you gone tanning in the last year on the following scale?
                1-5 (1)       6-10 (2)        greater than 10 (3)

            Have you ever gone tanning for a school dance, like homecoming, turnabout or prom?
                Yes (1)        No (2)

            On average, how often do you visit the tanning salon on the following scale?
                Once a week (1)       Twice a week (2) Three times a week (3)
                Once a month (4) Twice a month (5) Three times a month (6)
                Different Schedule (7) No schedule (8)

            How long do you tan at each session on the following scale?
                5 min     10 min      15 min    20 min       25 min    30 min

            Please respond with “true or false” to each of the following descriptions:
             a) I went tanning because I like how it makes me look.                 T (1)           F (2)
             b) I went tanning because I got coupons or it was inexpensive.         T (1)           F (2)
             c) I went tanning because many of my friends do it.                    T (1)           F (2)
             d) I went tanning to get a base layer before going on vacation.        T (1)           F (2)

(IF YES, SKIP THIS NEXT LINE OF QUESTIONING)
IF NO:
        Please respond with “true or false” to each of the following descriptions:
           a) I have no desire to go artificial tanning.                        T (1)               F (2)
           b) I don’t go tanning because I know it is dangerous.                T (1)               F (2)
           c) I don’t go tanning because I don’t have enough time.              T (1)               F (2)
           d) I don’t go tanning because I don’t have the money.                T (1)               F (2)
                                                                              Artificial Tanning      29


FOR ALL:
Does anyone in your family go tanning, if so, who?
       Mom (1)         Dad (2)           Brother (3)    Sister (4)        No one (5)      Other (6)

Do you think artificial tanning is safe?                        Yes (1)          No (2)

Have you ever seen advertisements for tanning salons?           Yes (1)          No (2)

Have you ever seen an educational sign, pamphlet, or advertisement expressing the dangers of tanning?
                                                               Yes (1)         No (2)

Do you smoke cigarettes?                                        Yes (1)          No (2)

Do you have a license and access to a car?                      Yes (1)          No (2)

Okay, that’s it. Thank you very much for your time and have a great day. Bye!

								
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